Treatment of Alzheimer&#39;s disease (AD) with aluminum oxyhydroxide

ABSTRACT

The invention discloses aluminium oxyhydroxide for use in the treatment and prevention of AD.

The present invention relates to means and methods for the treatment andthe prevention of Alzheimer's Disease (AD).

AD is characterized by the aberrant accumulation of Amyloid-βpolypeptides (Aβ) resulting in β-amyloid deposition. AD is the mostprevalent neurodegenerative disorder currently affecting 28 millionpeople worldwide. It typically presents with a characteristic amnesticdysfunction associated with other cognitive-, behavioural- andneuropsychiatric changes. AD is characterized by the abnormalaccumulation of intra- and extracellular amyloid deposits—closelyassociated with extensive astrocytosis and microgliosis as well asdystrophic neurones and neuronal loss. These amyloid deposits mainlyconsist of Aβ-peptides Aβ40 and Aβ42 derived from the Amyloid PrecursorProtein (APP; gi:112927), which is expressed on various cell types inthe nervous system. Aβ peptides are considered to be directly involvedin the pathogenesis and progression of AD.

Besides amyloid deposits, neurofibrillary tangles (NFT) embody thesecond characteristic neuropathological hallmark of AD, first describedby Alois Alzheimer. These lesions occur in the hippocampus, amygdaleassociation cortices, and certain subcortical nuclei. NFTs are locatedin the cytoplasm of neurons and are composed of hyperphosphorylated tauprotein. Tau is an axonal, microtubule binding protein that promotesmicrotubule assembly and stability under normal conditions.Hyperphosphorylation of Tau results in loss of microtubule associationand subsequent disassembly of microtubules, which in turn leads to animpairment of axonal transport and subsequent axonal and neuronaldegeneration. It is still unclear whether tau hyperphosphorylation andtangle formation are a cause or a consequence of AD.

Besides amyloid and Tau/hyperphosphorylated Tau pathology,neuroinflammation can be considered as the third integral pillar ofpathophysiologic changes causing neurodegeneration in AD. Theneuroinflammatory phenotype in AD is characterized by robust andwidespread activation of microglia and astrocytes in the affected brainregions, resulting in endogenous expression of pro-inflammatorycytokines, cell adhesion molecules, and chemokines. These changes arethought to result from glial reaction to events related to ongoingtoxicity elicited by amyloid and Tau/hyperphosphorylated Tau and theirmediators.

It is currently believed that one potential treatment strategy for ADand related disorders could be based on immunotherapy to prevent orreduce the accumulation of neurotoxic agents like Aβ orTau/hyperphosphorylated Tau.

Various active and passive treatment strategies targetingTau/hyperphosphorylated Tau led to a reduction ofTau/hyperphosphorylated Tau deposition and associated neuropathologicalchanges in animal models, however, no positive data in human AD patientsare available so far. Quite in contrast, there have been a significantnumber of clinical trial failures in the most recent past: Results “fromthe Phase III clinical trials of two monoclonal antibodies bapineuzumaband solanezumab that target amyloid-β indicated little clinical benefitof immunological attack on amyloid-β at the dementia stage of sporadicdisease” (Aisen et al., Nat. Rev. Drug Disc. 12 (2013), 324-325;Mullard, Nat. Rev. Drug Disc. 11 (2012), 657-660). Also other studies ofhypothesis-driven candidate disease modifiers “such as anti-inflammatorydrugs, secretase inhibitors and modulators, hormonal therapies, statinsand other drugs have been disappointing”, including the “clinicalfailure of the two leading γ-secretase inhibitors, semagacestat [..] andavagacestat” (Aisen et al., 2013; Mullard, 2012). Commentators havetermed this poor clinical outcome of AD clinical trials as “theculmination of a ‘lost decade’ in Alzheimer's disease therapeutictrials, with no substantial success since the approval of memantine”(Aisen et al., 2013). In the course of this development, the US-FDA alsoamended the rules for approving new treatments for AD and recommendedthe use of AD specific biomarkers, such as radiologic biomarkers usingPET (positron emission tomography) scans (Kozauer et al., N. Engl. J.Med. 368 (2013), 1170-1171).

WO 94/16327 A1 discloses therapeutic agents that involve an “amyloidprotein ion channel”. However, this concept of amyloid protein ionchannel of WO 94/16327 A1 was not further prosecuted and was finallychallenged scientifically (Sokolov et al., J. Gen. Physiol. 128 (2006),637-647; commentary by Eliezer, J. Gen. Physiol. 128 (2006), 631-633).

In addition, the teachings of WO 94/16327 A1 imply an active interactionof Al-ions with potential Aβ-Ion channels in vivo, thereby inhibitingthese channels. Thus, in order for aluminium to full fill this task, thecompound has to reach the brain as the site of activity in the suggestedconcentrations. In the human brain normal levels of aluminium range from0.25 to 0.75 mg/kg wet weight, with the grey matter (mainly responsiblefor regulating cognitive function affected in AD) containing about twicethe concentration found in the white matter (The EFSA Journal (2008)754, 24-88; Annex to the EFSA Journal (2008) 754, 1-34 opinion “Safetyof aluminium from dietary intake”). There is evidence that withincreasing age, aluminium concentrations may even increase in the humanbrain tissue. Similarly, several studies also indicate that brainsderived from AD patients show higher Al-levels than healthy controlbrains (reviewed in Yokel, NeuroToxicology 21 (2000), 813-828). Thus thesuggested therapeutically active Al concentration is already present inhealthy and diseased brain (in the range of the intended use-formulationas described in WO 94/16327 A1, claim 12: 0.01-10 mg/kg). In addition,bioavailability of Al in brain after parenteral and oral uptake is keptlow relying on actively regulated, highly efficient influx/effluxmechanisms and requires high peripheral doses to reach suggestedtherapeutic cerebral concentrations. It is therefore without plausiblescientific basis that an additional increase in peripheral Al would leadto additional cerebral Al levels required for exerting direct,therapeutically beneficial effects without eliciting potential toxiceffects.

Furthermore, FIGS. 7 and 8 of this application disclose that topicallyapplied aluminium-oxyhydroxide is able to lower cognitive declinesignificantly in an APP-transgenic model for Alzheimer's disease(Tg2576) without significantly changing cerebral Aβ levels. This isimplying an APP/Aβ independent mechanism underlying beneficialfunctional effects exerted by aluminium-oxyhydroxide in this AD model.

WO 99/27944 A1 discloses AD vaccines being essentially based on thepresence of an agent effective to induce an immunogenic response againstAβ. WO 2011/120924 A1 refers to an Aβ vaccine, which is essentiallybased on Aβ1-6 peptide bound to a virus-like particle. WO 2006/005707A2, WO 2009/149486 A2 and WO 2009/149485 A2 disclose Aβ mimotopepeptides for use in vaccines for the prevention and treatment of AD.

Heneka et al. (Nature, 493 (7434) (2012): 674-678) suggest the treatmentof AD by inhibition of NLRP3 in order to reduce amyloid-β aggregation.Aimanianda et al. (TIPS, 30 (6) (2009): 287-295) discloses that alumactivates NLRP3.

Magga et al. (J. Cell. Mol. Med. 16 (2012): 1060-1073) report theproduction of monocytic cells from bone marrow stem cells and theirtherapeutic use in AD. Lebson et al. (Cell Transp. Cogn. Com. 17 (2008):470/471) disclose monocyte gene therapy in AD APP+PS1 transgenic mice.WO 2012/055981 A1 suggests the use of a “TLR4 agonist free of endotoxin”for the prevention or reduction of amyloid deposition. Malm et al. (GLIA58 (2010): 889-900) review the role and therapeutic potential ofmonocytic cells in AD.

WO 2009/105641 A1 discloses the use of M-CSF for the treatment ofamyloidosis. Boissionneault et al. (Brain 132 (4) (2008): 1078-1092)report the effects of M-CSF on amyloid deposition and cognitiveimpairment in AD. Luo et al. (Neuroscience letters 367 (2) (2013):210-172) disclose that Colony-stimulating factor 1 receptor (CSF1R)signalling in injured neurons facilitates protection and survival.

Accordingly, so far no effective, disease modifying treatment isavailable to stop the progressive neurodegeneration and associatedcognitive decline in human patients. Available treatment modalities forAD include three acethylcholinesterase inhibitors (AChEI) and oneN-Methyl-D-aspartate (NMDA) antagonist. Their effects are small and onlysymptomatic in nature (see e.g. Corbett et al., Nat. Rev. Drug Discov.11 (2012), 833-846). Thus, there is a high medical need for adisease-modifying drug.

It is an object of the present invention to provide means and methodsfor the treatment and prevention of AD enabling a cure to AD in themeaning that the status of the diseased patient is not furtherdeveloping or even ameliorated. Another object is to provide means andmethods for preventing the development of AD in persons having or beingat risk of developing AD. More specifically, it is an object of thepresent invention to provide efficient AD treatment, as proven withrespect to at least one significant biomarker, as measured by brainimaging modalities using MRI (Magnetic resonance imaging) or emissiontomography based techniques.

Therefore, the present invention provides aluminium oxyhydroxide for usein the treatment and prevention of AD.

In the course of the present invention it has surprisingly turned outthat aluminium oxyhydroxide as active ingredient in a pharmaceuticalpreparation has proven in clinical trials to be effective in realdisease modifying effects in AD patients leading to clinical efficacyhitherto not seen in any of the clinical trials for AD medication sofar. The present invention therefore provides a breakthrough technologyfor this disease. For the first time, a significant disease modifyingeffect could be detected in AD patients. Moreover, the present inventionhas also turned out to be effective without the significant side effectsreported in other clinical trials for AD medication, especially in thefield of AD immunotherapy.

More specifically, the present invention has achieved a statisticallysignificant disease modifying effect in AD patients with respect to MRIscans of the volume of the (right) hippocampus. Moreover, for the firsttime, the correlation of a clinical biomarker and a radiologic biomarkerhas been shown in the course of clinical trials performed for thepresent invention. Structural MRI has been highlighted as a significantbiomarker, in the most recent scientific literature (Risacher et al.,Annu. Rev. Clin. Psychol. 9 (2013), 621-648; Vermuri et al., Neurology73 (2009), 287-293 and 294-301; Weiner et al., Alzh. Dememt. 9 (2013),e111-94; Frisoni et al., Nat. Rev. Neurol. 6 (2010), 67-77; Fox et al.,Arch. Neurol. 57 (2000), 339-344).

MRI provides great power to effect cross-sectional group-wisediscrimination and better correlation with general cognition andfunctional status cross-sectionally. MRI reflects clinically defineddisease stage even better than various CSF biomarkers tested (Vermuri etal., Neurology 73 (2009), 287-293 and 294-301). Numerous studies havedemonstrated significantly reduced hippocampal and entorhinal cortex(EC) volume, as well as reduced cortical thickness in the medial andlateral temporal cortex, parietal lobe, and frontal lobes, in patientsdestined to convert from MCI to probable AD (MCI-converters), up to twoyears prior to clinical conversion (Risacher et al., 2013).

Accordingly, this biomarker was investigated in the course of theclinical trials performed for the present invention in parallel with thestandard clinical parameters (monitoring functional and cognitivefunction of AD patients).

With the present invention, a significant improvement in the developmentof AD patients compared to the usual development of AD patients (gradualcognitive, functional and behavioural decline) can be achieved so as tosatisfy the long-felt need of providing a disease-modifying treatment ofAD.

The present invention comprises the effective administration ofaluminium oxyhydroxide (particularly as Alhydrogel) to AD patients.

Aluminium salts have a long-standing use as adjuvants in vaccines,however, during the years the pharmaceutical use of such salts has beenreduced to mostly two suspension preparations, namely Alhydrogel(aluminium-oxyhydroxide) and AdjuPhos (aluminiumhydroxyphosphate), ontowhich antigens are adsorbed for vaccine preparations (reviewed in E. B.Lindblad (2004) Vaccine 22, 3658-3668; E. B. Lindblad (2004) Immunologyand Cell Biology 82, 497-505; R. K. Gupta (1998) Adv. Drug Delivery Rev.32, 155-172).

Despite its long use, the mode of action of Alhydrogel as an adjuvant ispoorly understood. The initial hypothesis, that Alhydrogel forms a depotat the injection side has turned out to be only one part of amulti-faceted story (reviewed in C. Exley, P. Siesjo, H. Eriksson (2010)Trends Immunol. 31, 103-109; S. L. Hem, H. HogenEsch (2007) Expert Rev.Vaccines 6, 685-698; P. Marrack, A. S. McKee, M. W. Munks (2009) NatureRev. Immunol. 9, 287-293; S. G. Reed, M. T. Orr, C. B. Fox (2013) Nat.Med. 19, 1597-1608).

The main presentations of aluminium adjuvants used in humans arealuminium hydroxide (or aluminium oxyhydroxide) and aluminium phosphate.Both presentations are usually prepared by exposing a soluble aluminiumsalt (historically potassium alum, i.e. KAl(SO₄)₂.12H2O, was often used)to alkaline conditions, upon which a suspension is formed.Characterisation with X-ray crystallography and IR spectroscopy revealeda boehmite-like structure (aluminium oxyhydroxide) for aluminiumhydroxide and an amorphous structure corresponding to aluminiumhydroxyphosphate for aluminium phosphate.

Aluminium oxyhydroxide preparations have a point of zero charge at a pHof ˜pH 11, while aluminium hydroxyphosphate might have a point of zerocharge as low as pH 4 (depending on the phosphate content). Thereforealuminium oxyhydroxide and aluminium hydroxyphosphate have an oppositesurface charge at neutral pH, with the latter being negatively charged.It has to be mentioned, however, that the surface charge may changedepending on the exact buffer composition, especially phosphate ionshave the capacity to lower the surface charge of aluminium oxyhydroxide.

For aluminium oxyhydroxide, the preparation is devoid of an-ions such assulphates, nitrates, or chlorides and has a specified heavy metalcontent of less than 20 ppm. The suspension of aluminium oxyhydroxidehas a particle size distribution between 2 μm and approximately 10 μm,which are aggregates, composed of smaller fibers of preferably ˜2 nm×4.5nm×10 nm.

According to this most preferred embodiment, the current inventionrelates to the use of European Pharmacopoeial gradealuminium-oxyhydroxide (monograph 1664), more specifically to theproduct manufactured by Brenntag Biosector (2% Alhydrogel) testedtowards EP compliance. Alhydrogel is available in three varieties:Alhydrogel 1.3%; Alhydrogel 2% and Alhydrogel “85”. Alhydrogel 2% waselected as the International Standard Preparation for aluminiumhydroxide gels. The pharmaceutical preparation according to the presentinvention is aseptically formulated into a suitable buffer, preferablyan isotonic phosphate buffer (1 mM to 100 mM), preferably at aconcentration of ≥1.0 mg/ml Alhydrogel (given as Al₂O₃ equivalent; thismetric (Al as “Al₂O₃ equivalent”) is used generally for the presentinvention; accordingly, all doses and amounts for aluminium oxyhydroxidereferred to in the present application refer to Al₂O₃ equivalents (ofaluminium oxyhydroxide (Alhydrogel)), even more preferably at aconcentration of ≥1.5 mg/ml Alhydrogel (given as Al₂O₃ equivalent), mostpreferable at a concentration of ≥2.0 mg/ml Alhydrogel (given as Al₂O₃equivalent). The amount of aluminium salt for Alhydrogel is given asAl₂O₃ equivalent in line with the strength as stated by the manufacturer(i.e. 2% Alhydrogel equates to 2% Al₂O₃, i.e. 20 mg/mL). Thisconcentration is directly convertible into the respective concentrationof aluminium by using the respective molecular masses (20 mg/mL Al₂O₃(Mw 101,96)_corresponds to 10.6 mg/mL aluminium (molecular mass 26,98)).Depending on the salt used this value can easily be converted into thenecessary amount/concentration of a different aluminium salt (it isclear that these values are based solely on the amount of aluminium(salt), and other aspects, such as the contribution of the particulatenature of Alhydrogel is not taken into account).

Alhydrogel 2%, often also referred to as alum, is an aluminiumoxyhydroxide wet gel suspension.

In the most preferred embodiment of the present invention, the aluminiumoxyhydroxide to be administered to the AD patient is an aluminiumoxyhydroxide suspension, preferably European Pharmacopoeia gradealuminium-oxyhydroxide (monograph 1664), especially Alhydrogel. Thealuminium oxyhydroxide is administered in an amount effective to achievean AD ameliorating effect, as defined by the EMEA Guideline on medicalproducts for the treatment of AD and other dementias (Document Ref.CPMP/EWP/553/95 Rev.1 of 24 Jul. 2008). Accordingly, any administrationprocedure or dosage regimen for the aluminium-oxyhydroxide formulationaccording to the present invention that is suitable to achieve the ADmodifying effect as provided by the present invention is subject to thepresent invention. Although it is possible to deliver the preparationaccording to the present invention by way of slow infusion, thepreferred strategy for administration is by administration of doses, forexample by subcutaneous injection. Preferably, therefore theadministration dose of aluminium oxyhydroxide is of at least 0.5 mg,preferably at least 1.0 mg, especially at least 1.2 mg, to an ADpatient. A preferred range of amount to be administered to a patient isan amount of aluminium oxyhydroxide of 1.2 mg to 5.0 mg. The ADameliorating effect of aluminium oxyhydroxide administration is evenmore pronounced at an amount of at least 1.5 mg. According to anotherpreferred embodiment aluminium oxyhydroxide is administered in an amountof 1.5 mg to 5.0 mg, preferably 1.5 to 3.0 mg, especially 1.5 to 2.5 mg,to an AD patient. Another preferred embodiment comprises administrationof aluminium oxyhydroxide in an amount of 1.6 mg to 2.5 mg, preferably1.8 to 2.2 mg, especially 1.9 to 2.0 mg, to an AD patient.

According to another preferred embodiment, the aluminium oxyhydroxide isadministered in amount of 2.2 mg or higher. This amount is even higheras prescribed in the US general biological products standards (U.S.C. 21CFR 610.15 (as of 1 Apr. 2013)). Such preferred higher ranges ofaluminium oxyhydroxide are i.a. 2.2 to 10 mg, 2.2 to 8 mg, 2.2 to 5 mg,and 2.2 to 4 mg for one administration dose.

Preferably, the aluminium oxyhydroxide is the single effective substanceto be applied in the administration dose. The aluminium oxyhydroxidepreparation according to the present invention may, however, containvarious auxiliary substances that have no specific clinical effect butare useful in the dosage form to be administered, be it foradministration purposes, storage purposes, or other purposes. Accordingto a preferred embodiment, the aluminium oxyhydroxide preparation to beapplied according to the present invention contains a pharmaceuticallyacceptable carrier, diluent or excipient, for example water forinjection. Preferably, the aluminium oxyhydroxide preparation accordingto the present invention additionally contains one or morestabilisators, especially thiomersal, detergents, antioxidants,complexing agents for mono- or divalent metal ions, especiallyethylenediaminetetraacetic acid (EDTA), sugars, sugar alcohols,glycerol, and/or buffer substances, especially TRIS or phosphate buffersubstances. This, of course, also includes mixtures of such auxiliarysubstances.

The dosage form to be administered to the patients can be provided inany convenient volume, preferably as injectable suspension, e.g. with avolume of between 0.1 and 10 ml, more preferred of 0.2 to 5 ml,especially of 0.4 to 3 ml. Specifically preferred volumes are 0.5, 1,1.5 and 2 ml. The pharmaceutical preparations according to the presentinvention are produced according to pharmaceutical Good ManufacturingPractice (GMP), as required and defined by the European and/or USPharmacopeia.

According to a preferred embodiment, the aluminium oxyhydroxide isadministered to a patient in a suspension with a pH of 4 to 10,preferably of 5 to 9, more preferred of 6 to 8, especially from 7.0 to7.5. Preferably, the suspension is an isotonic suspension.

Preferably, the aluminium oxyhydroxide is administered by a route thatis as convenient as possible for the AD patient but is still effectiveto achieve an AD modifying effect. Most effective treatment routes ofaluminium oxyhydroxide according to the present invention aresubcutaneous, intranodal, intradermal, or intramuscular administration,especially subcutaneous administration. Subcutaneous administration isperformed as a bolus into the subcutis, the layer of skin directly belowthe dermis and epidermis, especially in the fatty tissue in thesubcutis.

Administration regimes can be optimised individually for each ADpatient, depending on the treatment success, as measured by variousparameters, especially by cognitive and functional performances and bybiomarkers, especially PET scans concerning hippocampus volume (seebelow). In the course of the clinical trials conducted for the presentinvention, at least monthly administrations of aluminium oxyhydroxide toan AD patient have proven to be successful in ameliorating AD. In orderto achieve a long lasting therapeutical effect, such at least monthlyadministrations should be continued for at least three months,especially at least six months.

Administration of the aluminium oxyhydroxide according to the presentinvention may also be performed at least twice a month (for examplebi-weekly or weekly); also in such a dosage regimen, aluminiumoxyhydroxide should be administered to an AD patient at least for aperiod of three months, preferably for at least six months, morepreferred for at least twelve months, especially at least 24 months.

According to a preferred embodiment aluminium oxyhydroxide isadministered to an AD patient subcutaneously in the (outer area of the)upper arm, preferably alternating in the left and in the right upper arm(i.e. administering the first dose into the right (or left) upper armand the second dose into the left (right arm), and so on). Otherconvenient (or alternative) areas for subcutaneous administration arejust above and below the waist (except the area right around the navel(a 2-inch circle)), the upper area of the buttock, preferably justbehind the hip bone, the front of the thigh, midway to the outer side, 4inches below the top of the thigh to 4 inches above the knee, etc.

Alternatively, the dose to be administered can also be split into two(or more) split doses that are administered simultaneously (at the samephysician date; at least at the same day) to the AD patient. Forexample, a dose of 2 mg may be split to split doses of 1.8 and 0.2 mg,1.7 and 0.3 mg, 1.5 and 0.5 mg, 1.34 and 0.76 mg, 1.0 and 1.0 mg, 1.05and 0.95 mg, 1.0, 0.5 and 0.5 mg, 0.6, 0.6 and 0.7 mg, 0.2, 0.5, and 1.3mg, 0.5, 0.5, 0.5 and 0.5 mg, 0.2, 0.3, 0.5 and 1.0 mg, etc. The splitdoses may be administered at different administration sites or,preferably, at the same site of administration. The “same site ofadministration” is within an area of 10 cm² of the skin, preferablywithin an area of 5 cm² of the skin, especially within 1 cm² of theskin. Preferred split doses contain aluminium oxyhydroxide in an amountof 0.8 to 5.0 mg, preferably of 1.0 to 3.0, especially from 1.0 to 1.5mg.

In order to achieve a very long lasting effect of the AD amelioration,the treatment according to the present invention is performed for longerthan one year. According to a preferred embodiment of the presentinvention, the aluminium oxyhydroxide is administered at least monthlyfor at least two years, preferably at least four years, especially atleast 8 years, to an AD patient.

Administration of the aluminium oxyhydroxide according to the presentinvention may be performed by any suitable administration device. Forconvenience reasons, the aluminium oxyhydroxide dose is administered byan injection device, especially a syringe, to an AD patient. Thepharmaceutical preparations for use in the present invention can beprovided in any suitable form. Preferably, they are provided in astorage stable form. Storage stability can be assured by various means,such as sterilisation, addition of stabilisers, freezing,lyophilisation, etc. Preferably, combinations of such means are used toenhance storage stabilities of such preparations. When aluminiumoxyhydroxide containing compositions are frozen or lyophilized, anaggregation of adjuvant particles during processing may be observed. Bycooling such aluminium oxyhydroxide (Alhydrogel) formulations at fasterrates or by the addition of sufficient amounts of a glass formingexcipient, such as trehalose, aggregation of Alhydrogel, can beprevented or minimized. It was proposed that freeze-concentration ofbuffer salts induces modifications in surface chemistry andcrystallinity of such aluminium agents, which in turn favouraggregation. These modifications and the resulting aggregation of suchAlhydrogel particles can be excluded or minimized through choice ofbuffer ions, or kinetically inhibited by rapidly forming a glassy stateduring freezing (see e.g. Clausi et al., J Pharm Sci. 2008 June;97(6):2049-61).

The pharmaceutical compositions to be applied to AD patients accordingto the present invention are manufactured (and finished) into suitablecontainers, and sold for example in sealed vials, ampoules, cartridges,flexible bags (often constructed with multi-layered plastic), glass orpolypropylene bottles or, preferably, in syringes, especially inprefilled (ready-to-use or ready-to-reconstitute) syringes.

According to a preferred embodiment of the present invention, thealuminium oxyhydroxide is administered in an amount of at least 1.8 mgto an AD patient.

Preferred patients to which aluminium oxyhydroxide preparationsaccording to the present invention are administered are AD patients thatare early stage patients, including those patients that are often alsoreferred to as “patients with mild cognitive impairment” (MCI). Theconcept of MCI was developed in the 1990s to capture patients with earlyclinical signs of Alzheimer disease (AD) who did not yet fulfil thecriteria for dementia. The amnestic variant of MCI features thefollowing: memory complaints, preferably qualified by an informant;memory impairment for age, as indexed by low cognitive performance inone or more neuropsychological tests that tap into learning abilities(for example, prose recall, word list); preserved general cognitivefunction (for example, Mini-Mental State Examination score of 24 out of30 or above); intact activities of daily living; and no dementia. Abouttwo-thirds of all patients with amnestic MCI harbour the pathologicalfeatures of AD and develop the clinical syndrome of Alzheimer dementiawithin 5 years, whereas the remaining one-third have non-progressive orvery slowly progressive causes of cognitive impairment (for example,depression or age-related cognitive impairment). Proposed new diagnosticcriteria for AD developed in 2007 (Dubois et al., Lancet Neurol. 6(2007), 734-746) suggested that the disease can be recognized at the MCIstage if the patient is positive for at least one of the following fourmarkers: medial temporal atrophy on MRI; temporoparietal corticalhypometabolism on 18F-fluorodeoxyglucose PET; abnormality ofcerebrospinal fluid markers (tau, amyloid-β42 or phospho-tau); andpositivity on amyloid imaging with PET. This patient population is notonly included in the AD patients to be treated according to the presentinvention, it is a specifically preferred group of patients for whichthe treatment method according to the present invention is specificallyeffective. This is in line with the revised criteria for AD clinicaltrials adopted by the USFDA (Aisen et al., 2013; Kozauer et al., 2013).Accordingly, it is preferred to treat patients in an early state of AD,as defined by a relatively high MMSE (mini-mental state examination orFolstein test) score. Preferably the AD patient to be treated accordingto the present invention is a patient with an MMSE score of between 23and 30 (30 being the maximum), preferably between 24 and 30, morepreferably between 25 and 29, especially between 26 and 29. Otherpreferred patient groups are patients greater than or equal to 27 points(indicating a normal cognition), 25 to 27 (slightly below normalcognition) or 19 to (mild points cognitive impairment).

Early stage AD patients can also be selected by other scores, preferablyscores that combine cognitive and functional parameters (and numericallimits) for limiting AD population to be (effectively treated), such asADAS-cog, etc.

The present invention provides for the first time an AD treatment thatis disease modifying. The effectiveness of the treatment according tothe present invention is proven by the parameters required by the drugauthorisation authorities, especially the EMEA and the US-FDA. Forexample, the EMEA guideline for AD treatment requires primary endpointsreflecting the cognitive and the functional domain. Accordingly, acombined (Composite) score is used for the clinical assessment of thepresent invention. This composite score combines two established scores,one for the cognitive function (ADAS-cog (Alzheimer's Disease AssessmentScale-cognitive subscale)) and one for the functional ability (ADCS-ADL(Alzheimer's Disease Cooperative Study-Activities of Daily LivingInventory)). The adapted ADAS-cog combines items that assess cognitivefunction. The adapted ADCS-ADL includes items that are sensitive tofunctional ability. Cognitive skills are expected to decline toward thebeginning of the disease and one's ability to perform basic functionsare expected to decline later in the disease. The combined primaryoutcome (Composite score according to the present invention) combinesboth the adapted ADAS-cog and adapted ADCS-ADL to create a compositethat is sensitive to decline in cognitive and basic functions. Thefollowing equation is used to derive the combined primary outcome, i.e.combined composite:

Combined composite according to the present invention: =1.67*Wordrecall+1.35*Orientation+1.42*Word Recognition+0.55*RecallInstructions+0.81*Spoken Language+1.01*WordFinding+5.42*ONB+0.15*VPAL+0.19*CategoryFluency+0.28*Belongings+0.35*Shopping+0.23*Hobbies+0.38*Beverage+0.37*Meal+0.23*CurrentEvents+0.26*TV+0.33*KeepingAppointments+0.37*Travel+0.33*Alone+0.35*Appliance+0.49*Clothes+0.36*Read+0.62*Telephone+0.33*Writing

Furthermore, AD biomarkers were observed with the present invention thatare characteristic for AD development. EMEA and FDA criteria recommendnewer techniques, such as MRI, especially atrophy of entorhinal or(para-) hippocampal cortex. With the present invention, structural MRIwas applied. More specifically, volume of right hippocampus (importantfor learning and memory of material that is difficult to verbalise) isused according to the present invention as significant AD biomarker fortreatment success.

According to the present invention, a clinical effect in AD treatmentcan be observed which can be measured by a reduction in cognitive and/orfunctional decline (over a treatment period of about one year) by atleast 30% (calculated by the score decline), preferably by at least 50%,especially by at least 70%, compared to a normal development of declinein AD patients. Preferably, cognitive and functional parameters remainessentially unchanged during treatment. This can be achieved by thepresent invention especially in patients with earliest stage patients(as suggested and recommended by the guidelines of EMEA and FDA), forexample AD patients with MMSE of 23 or higher, preferably of 24 orhigher, more preferred of 25 or higher, especially of 26 or higher. Forthose patients, Composite score change during treatment according to thepresent invention was still around the initial score after 18 months.This is significantly more than the minimum requirements for “diseasemodifying effects” as required by the EMEA (“From a regulatory point ofview, a medicinal product can be considered as disease modifying, if theprogression of the disease as measured by cognitive and functionalassessment tools is reduced or slowed down and if these results arelinked to an effect on the underlying disease process”; “a diseasemodifying effect will be considered when the pharmacologic treatmentdelays the underlying pathological or pathophysiological diseaseprocesses and when this is accompanied by an improvement of clinicalsigns and symptoms of the dementing condition”).

The invention is further explained by way of the following examples andthe figures, yet without being limited thereto.

FIG. 1 shows the results of the clinical trial according to the presentinvention with respect to the change in Composite score composed of(partial) Adapted ADL change and Adapted ADAS-cog change for allpatients who have received the 2 mg and 1 mg aluminium oxyhydroxidetreatment.

FIG. 2 shows a comparison of the mild population of patients (the mildpopulation is defined by a baseline MMSE score of 24 and higher) of bothgroups showed that this effect is most pronounced in the cohort ofpatients in earlier disease stages.

FIG. 3 shows slowing of disease progression apparent in the 2 mg and 1mg aluminium group as evidenced by Adapted ADAS-cog (ADAS-cog itemsonly; Least Squares Means) for the 1 mg and mg aluminium oxyhydroxidegroup compared to the historical control (p-values: 1 mg vs.HC-ADNI,NS,HC: <0.0001; 2 mg vs. HC-ADNI,NS,HC: <0.0001).

FIG. 4 shows development of volume (in mm³) of right hippocampus for 2mg and 1 mg aluminium oxyhydroxide treatment group of the mildpopulation of patients (the mild population is defined by a baselineMMSE score of 24 and higher), showing that this effect is mostpronounced in the cohort of patients in earlier disease stages.

FIG. 5 shows the Quality of Life-Alzheimer's disease (QOL-AD) forcaregivers. Caregivers completed the measure as a questionnaire abouttheir patients' QOL. The measure consisted of 13 items, rated on a 4point scale, with 1 being poor and 4 being excellent. Outcomes are shownas the change over time using a least squares means from a mixed model.

FIG. 6 shows immune response of the mice tested in the Tg2576 animalmodel: Tg2576-mice were injected 6×, s.c., at 4-week intervals witheither conjugate-vaccine containing 30 μg net peptide, KLH formulatedwith Alum or Alum only. Alum doses used were equivalent to 2 mg/ml.Vaccination induced Abs were measured in plasma samples taken atsacrification (SeqID 1 (n=10), SeqID 2 (n=8), KLH-Alum (n=10) and Alumonly (n=8)). Samples were analyzed for their concentration of IgG Absagainst specific peptides. Values depicted are the titer calculated asOD max/2 (at 405 nm) plus SEM. IgG response towards the respectiveimmunizing peptide (SeqID 1: anti SeqID 1; SeqID 2: anti SeqID 2,KLH-Alum: anti KLH, Alum: anti AD02); B) Reactivity towards humanAβ1-40/42 after immunization. SeqID 1 (n=10) and SeqID 2 (n=8), treatedanimals show anti Aβ40/42 reactivity, KLH-Alum and Alum only treatedanimals do not show reactivity above background. Background for thisassay was set to 1/100, indicated by black lines and an asterisk in A+B.

FIG. 7 shows memory and learning of the mice tested: Groups of Tg2576mice (n≤10/group) received 6 monthly injections of KLH/ALUM (n=9) orSeqID 1-KLH-Alum (n=10)-, SeqID 2-KLH-Alum (n=7)-conjugate vaccines orALUM only (n=8). Naïve wt animals (n=20) were used as positive controlsfor Contextual fear conditioning (CFC). Contextual learning and memorywas assessed by CFC-analysis using % of time freezing at the end of CFCtesting. Parameter depicted is the % of time the animals are 99%immobile during a representative 2-minute period on day two of the CFCtesting paradigm. *..p<0.05; **..p<0.01.

FIG. 8 shows amyloid load in the animals tested: Groups of Tg2576 mice(n≤10/group) received 6 monthly injections of KLH/ALUM (n=9) or SeqID 1(n=10)-, SeqID 2 (n=7)-conjugate vaccines or ALUM only (n=8). Alum dosein all formulations equivalent to 2 mg/ml. Brains were isolated, 8 weeksafter the 6^(th) immunization. Quantification of the relative totalbrain area covered by amyloid deposits (in % of total tissue analyzed)is based on immuno-fluorescence staining using the Aβ specific mAb 3A5.Representative subregions of the cortex (A, B) and dentate gyrus (C, D)of controls (A, C) and SeqID 1-(B, D) immunized mice are shown. E) SeqID1-KLH Alum+SeqID 2-KLH Alum reduces the relative area covered by amyloiddeposits compared to KLH-Alum controls significantly (diffuse and densecored amyloid; *..p<0.05, **..p<0.01). A slight but insignificantreduction in Aβ deposition is detectable in Alum only treated vs.KLH-Alum treated animals. (ns) Arrowhead in C indicates unspecificfluorescence from a cerebral vessel. Scale bar: 200 μM; pictures takenat 10× magnification.

EXAMPLES 1. Excerpt of an AD Clinical Trial (AFF006; Eudract:2009-016504-22)

Materials and Methods:

Data supporting the invention are derived from a randomized clinicaltrial in early AD patients. The study (AFF006; Eudract: 2009-016504-22)randomized early AD patients into 5 treatment arms. Patients of 2 studyarms received either 1 mg aluminium or 2 mg aluminium. In total, 99early AD patients were enrolled into the 2 study arms. Participation ofa given patient lasted 18 months.

Study Design:

AFF006 was conducted as a randomized, placebo-controlled, parallelgroup, double-blind, multi-center phase II study and assessed theclinical and immunological activity as well as the safety andtolerability of repeated s.c. administrations of i.a. aluminium(different doses) in patients with early AD, as defined in the protocol.It was performed in a total of 6 countries: Austria, France, Germany,Slovakia, Czech Republic and Croatia.

The clinical trial comprised 10 regular outpatient visits and 6telephone interviews. Up to four weeks before start of treatment, ascreening visit (Visit 1) was performed to ensure suitability of thepatients for the clinical trial and to establish the patients' baselinecharacteristics. Following screening, eligible patients were randomlyallocated to the treatment groups. After randomization at week 0,patients received 6 injections with either 1 or 2 mg aluminium.Injections were applied s.c. by the investigator at weeks 0, 4, 8, 12,40 and 65 (Visit 2, 3, 4, 5, 7 and 9).

At Visits 2, 3, 4, 5, 6, 7 and 9 possible local and systemic reactionsto the vaccine and vital signs (blood pressure, heart rate, respiratoryrate and body temperature) were assessed. In addition, a physical andneurological examination was performed. Efficacy parameters wereassessed at Visits 1, 2, 3, 5, 6, 7, 8, 9, 10. The final visit (Visit10) was performed twelve weeks after the last administration of studydrug (Visit 9). An early discontinuation visit (EDV) was performed whena patient discontinued from the clinical trial.

Study Population

The study was done in patients with early AD. Diagnosis was defined bythe following criteria:

-   -   probable Alzheimer's disease as defined by NINCDS/ADRDA criteria        (1)    -   MMSE score ≥20 (2)    -   result of Free and Cued Selective Reminding Test (FCSRT) result        of total recall ≤40 or free recall ≤17, indicating hippocampal        damage impairing the patient's episodic memory (3)    -   the result of a centrally read MRI of a patient's brain must be        compatible with the diagnosis AD, in particular, presence of a        medial temporal lobe atrophy (Scheltens Score ≥2) (4)

Other in-/exclusion criteria applied (e.g., written informed consent;age between 50 and 80 years, treatment with immunosuppressive drugs(exclusion)).

Administration of Study Drug

During the study Visits 2, 3, 4, 5, 7 and 9 the patient received studydrug by the investigator, in total: six injections over a 65-weektreatment period. Injections were applied to the external surface of theupper arm, approximately 8-10 cm above the elbow. Prerequisite regardingthe actual site was the presence of an intact regional lymph nodestation. If the draining lymph node stations of both upper arms were notintact, injection was placed into the thigh close to the inguinal lymphnodes. Two alternating injection sites (e.g. left and right upper arm,left upper arm and left thigh) were used throughout the 6 injections.

Injections were applied to the subcutaneous tissue (s.c.). Special carewas taken to avoid intravasal application by careful aspiration beforeeach injection. All administrations were performed at the trial site.

Volume-Based Morphometry

Hippocampus (left and right), and whole lateral ventricle ROIs weredelineated on an anatomical MRI template in order to generate the atlasfor volumetric measures. The volumes of the hippocampus and lateralventricles for each subject were determined using a fully-automatedmethod which combines transformations derived from the nonlinearregistration of the atlas labels to individual subject scans andsubject-specific image information (Collins et al., J. Comput. Assist.Tomogr., 18: 192-205, 1994). Lateral ventricle and hippocampalsegmentations that failed post-processing QC review were manuallycorrected. The total intracranial volume (TIV) was estimated from thebrain mask generated during pre-processing and the average TIV(TIV_(avg)) for each subject was determined by averaging the estimatedTIV across visits. The normalization factor(TIV_(template)/TIV_(avg_)subject) was used to normalize the hippocampaland ventricular volumes for each subject in order to account fordifferences in head size.

Safety Assessments:

Safety evaluations included the following:

adverse events (AEs) and serious adverse events (SAEs) (number ofpatients who withdrew due to AEs; reason for withdrawal)

Laboratory assessments: hematology, biochemistry, coagulation, serology,urinalysis, APP crossreactivity

vital signs (blood pressure, heart rate, respiratory rate and bodytemperature)

physical and neurological examination

Efficacy Assessments:

The primary efficacy variables are the change from baseline (CFB) incognition as measured by an adapted ADAS-cog, CFB in function asmeasured by an adapted ADCS-ADL and a combination of CFB in cognitionand function as measured by a combined composite:

1. Co-Primary: Adapted ADAS-cog;

2. Co-Primary: Adapted ADCS-ADL;

3. Combined Primary Outcome: Composite.

ADAS-cog and other items included in the adapted ADAS-cog were measuredat Visits 1, 2, 3, 5, 6, 7, 8, 9 and 10 or EDV. ADCS-ADL were measuredat Visits 2, 5, 6, 7, 8, 9 and 10 or EDV. Items that contributing to thecombined primary outcome were measured at Visits 2, 5, 6, 7, 8, 9 and 10or EDV.

The primary efficacy outcomes all range from 0 to 100. For each adaptedscale and composite, a lower score indicates better performance.However, some items included in a scale may be opposite in direction,i.e. a higher score indicates better performance. Before a composite wascalculated, contributing items that are scored in the opposite directionwere reversed. An item is reversed in score by subtracting the observedvalue from the maximum possible value for the item. This reverses thescale of the items so that a lower score now indicates betterperformance. The following items included in the adapted ADAS-cog andcombined composite require reverse scoring: Verbal PAL, NTB CategoryFluency and CogState ONB.

Secondary Efficacy Outcomes:

Quality of Life (QOL) Caregiver

QOL caregiver is a brief, 13-item questionnaire designed to specificallyobtain a rating of the QOL of the patient from the caregiver'sperspective. Questions cover relationships with friends and family,concerns about finances, physical condition, mood, and an overallassessment of life quality. All items are rated on a four-point scale,with 1 being poor and 4 being excellent. The total score is the sum ofall items, which can range from 13 to 52. QOL caregiver values arepresented here as the change from baseline. Outcomes were measured atVisits 1, 6, 8, and 10.

Statistical Analysis

Baseline Data

Subjects were described using demographic information and baselinecharacteristics recorded during the screening phase (Visit 1).

Demographic information assessed was age, gender, racial group, smokinghabits, level of education, height and weight. Subject demographics wassummarized by treatment for the Safety, ITT and Per Protocolpopulations.

Primary Efficacy Analysis

The primary, secondary and exploratory efficacy outcomes were analyzedby comparing change over time between the groups. The efficacy analysesutilized the mixed model described below. The mixed model analysiscompared the estimated change from baseline between the 3 vaccine andthe 2 aluminium groups in all efficacy outcome scores at each visit. Themodel used separate repeated measures longitudinal models for eachefficacy endpoint. This analysis assessed whether or not there is adifference in estimated CFB values between treatment groups.

SAS⋅PROC MIXED was used to fit a mixed model with repeated measures(MMRM), with CFB of each of the efficacy outcomes (e.g., AdaptedADAS-cog) as the response variable and the following covariates andfixed effects:

Age (covariate);

Level of Education (fixed effect split into categories of ≤12 years, >12years);

Gender (fixed effect);

Baseline Test Score of Efficacy Parameter (covariate);

Center (fixed effect);

Treatment (fixed effect);

APOEe4 status (fixed effect, positive or negative);

Use of AChE Inhibitors (fixed effect, determined from medications);

Time (covariate, time will be defined in terms of visits);

Time by Treatment Interaction (Time*Treatment);

The covariance structure for the model was first-order heterogeneousautoregressive (ARH[1]). Least-squares means were estimated at eachvisit in the study. The LS mean at a particular visit was interpreted asthe expected CFB in the efficacy outcome at that time point (Visit) whenthe specified treatment was administered. Least squares means andstandard errors were estimated from the mixed model at each visit andare shown for the various groups.

The adapted ADAS-cog combines items that assess cognitive function. Theadapted ADCS-ADL includes items that are sensitive to functionalability. Cognitive skills are expected to decline toward the beginningof the disease and one's ability to perform basic functions are expectedto decline later in the disease. The combined primary outcome (referredto herein as “Composite score”) combines both the adapted ADAS-cog andadapted ADCS-ADL to create a Composite score that is sensitive todecline in cognitive and basic functions. The following equation is usedto derive the combined primary outcome, i.e. combined Composite score:

Combined Composite Score:

=1.67*Word recall+1.35*Orientation+1.42*Word Recognition+0.55*RecallInstructions+0.81*Spoken Language+1.01*WordFinding+5.42*ONB+0.15*VPAL+0.19*CategoryFluency+0.28*Belongings+0.35*Shopping+0.23*Hobbies+0.38*Beverage+0.37*Meal+0.23*CurrentEvents+0.26*TV+0.33*KeepingAppointments+0.37*Travel+0.33*Alone+0.35*Appliance+0.49*Clothes+0.36*Read+0.62*Telephone+0.33*Writing

The percent contribution of each item to the combined Composite scorecan be found in Table 1 below: Item Percent Contribution ADAS-cog WordRecall 16.6 ADAS-cog Orientation 10.8 ADAS-cog Word Recognition 17.0ADAS-cog Recall Instructions 2.8 ADAS-cog Spoken Language 4.1 ADAS-cogWord Finding 5.1 CogState One-Back Memory 8.5 NIB VPAL 8.5 NIB CategoryFluency 8.5 ADCS-ADL Belongings 0.8 ADCS-ADL Shopping 1.4 ADCS-ADLHobbies 0.7 ADCS-ADL Beverage 1.1 ADCS-ADL Meal 1.5 ADCS-ADL CurrentEvents 0.7 ADCS-ADL TV 0.8 ADCS-ADL Keeping Appointments 1.0 ADCS-ADLTravel 1.5 ADCS-ADL Alone 1.0 ADCS-ADL Appliance 1.4 ADCS-ADL Clothes1.5 ADCS-ADL Read 0.7 ADCS-ADL Telephone 3.1 ADCS-ADL Writing 1.0Results

AFF006 recruited a study population reminiscent of early AD patientsbased on demographic data (Table 2) and data showing the baselinecharacteristics of the study groups (Table 3).

Both the frequency and the intensity of the local reactions depend onthe aluminium dose administered (Table 4). Such local reactions (LR)serve as a measure of the activation of the innate immune response.

2 mg aluminium group compares favourably even to the 1 mg aluminiumgroup (other groups) with regard to parameters informing on theprogression of the disease (FIGS. 1 and 5). Comparison of the mildpopulation of patients of both groups showed that this effect is mostpronounced in the cohort of patients in earlier disease stages (FIG. 2).Slowing of disease progression over 18 months is specifically apparentin the 2 mg aluminium group, exemplified with Adapted ADAS-cog (FIG. 3).

Results obtained were compared to public datasets. Historical datasetsidentified were the ADNI 1 mild AD cohort (observational study), themild placebo patients from the ADCS Homocysteine trial (HC, MMSE>=20)and the placebo group from the ADCS NSAID study of Rofecoxib andNaproxen (NS, MMSE>=20). These 3 cohorts were combined to yield thehistorical control (HC-ADNI,NS;HC). Data points were available for 344patients at month 6, 317 patients at month 12 and 226 patients at month18. The ADNI trial only performed assessments at 6, 12 and 24 months, sothe 18 month value was imputed with a straight line. The NS study wasonly 12 months long, so no 18 month data was available from this study.

Although the adapted ADAS-cog used some items from the ADAS-cogsupplemented with items from the NIB and the CogState Battery, theseitems were not available for all of the historical studies. So, anadapted ADAS-cog 2 was created which used the same weightings as theadapted ADAS-cog for the ADAS-cog items, but did not include the NIB andCogState items (1.67*Word recall+1.35*Orientation+1.42*WordRecognition+0.55*Recall Instructions+0.81*Spoken Language+1.01*WordFinding).

The adapted ADAS-cog2 shows substantially more decline in the historicalcontrol group than the 1 and 2 mg aluminium oxohydroxide treated groupsfrom the AFF006 study (FIG. 3). The p-values were: 1 mg vs. HC-ADNI, NS,HC: <0.0001; 2 mg vs. HC-ADNI, NS, HC: <0.0001.

Also the MRI data show a statistically significant disease modifyingeffect for the 2 mg group of patients and a correlation of thehippocampus volume with clinical endpoints, e.g. right hippocampus withadapADAS: p=0.0006 or Composite score: p=0.0095) (FIG. 4). It has to bespecifically mentioned that the present investigation has provided forthe first time a parallel development of clinical data with a radiologicbiomarker (MRI in the present case)). FIG. 4 shows that the patientstreated according to the present invention showed almost no AD relatedreduction in hippocampus volume over a period of 18 months whereas therate of brain atrophy per year in AD patients is in the range of 3 to 6%per year (Risacher et al., 2013, Table 2; the rate in healthy elderlyindividuals is usually in the range of 0.5 to 2.2 (see also this table 2in Risacher et al.).

FIG. 5 shows that caregivers of patients treated according to thepresent invention rated the QOL of the patient as significantly improvedover a period of 18 months following 2 mg compared to 1 mg Alum andother groups (not shown).

TABLE 2 Patient Population and Disposition 1 mg 2 mg Patient Disposition(N = 48) (N = 51) Number of Subjects n (%) Completed 41 ( 85.4%) 45 (88.2%) Discontinued  7 ( 14.6%)  6 ( 11.8%) P-value¹ Reason forDiscontinuation from the Study: Death 2 ( 4.2%) 0 ( 0.0%) Adverse Event0 ( 0.0%) 0 ( 0.0%) Withdrawal by Subject 4 ( 8.3%) 5 ( 9.8%) Lost toFollow-up 0 ( 0.0%) 0 ( 0.0%) Other 1 ( 2.1%) 1 ( 2.0%)

TABLE 3 Demographics—Race, Gender, Education, Age 1 mg 2 mg Demographics(N = 48) (N = 51) Race Asian/Pacific 0 ( 0.0%) 1 ( 2.0%) IslanderCaucasian 48 (100.0%) 50 ( 98.0%) Gender Male 28 ( 58.3%) 19 ( 37.3%)Female 20 ( 41.7%) 32 ( 62.7%) P-value¹ Education Years Mean (SD) 12.3(4.03) 11.8 (3.18) Median 12 11 (Q1, Q3)  (9.0, 15.0) (10.0, 13.0) Min,Max  8, 26  6, 22 P-value¹ Age (yrs) n 48 51 Mean (SD) 70.3 (6.56) 68.9(8.36) Median 71 69 (Q1, Q3) (65.0, 75.5) (64.0, 77.0) Min, Max 57, 8050, 80 P-value¹ Weight (kg) n 48 51 Mean (SD) 70.45 (10.375) 67.62(13.700) Median 70.5 65 (Q1, Q3) (64.00, 77.70) (57.00, 78.00) Min, Max 47.5, 101.0  45.0, 100.0 P-value¹ BMI (kg/m²) n 48 51 Mean (SD) 24.66(2.903) 24.81 (3.627) Median 24.8 24.2 (Q1, Q3) (22.95, 26.15) (22.30,27.30) Min, Max 17.8, 31.2 18.2, 35.4 P-value¹

TABLE 4 Adverse Event Summary of Local Reactions MedDRA System OrganClass 1 mg 2 mg Preferred Term (N = 48) (N = 51) Number of subjects with31 ( 64.6%) 42 ( 82.4%) reported adverse event Number of unique events96 162 General Disorders and 31( 64.6%), 209 42( 82.4%), 487Administration Site Conditions Injection Site Erythema 26 ( 54.2%), 6437( 72.5%), 143 Injection Site Swelling 13 ( 27.1%), 27 26 ( 51.0%), 86Injection Site Warmth 18 ( 37.5%), 31 25 ( 49.0%), 67 Injection SiteInduration 13 ( 27.1%), 32 14 ( 27.5%), 34 Injection Site Pain 14 (29.2%), 41 31 ( 60.8%), 99 Injection Site Pruritus 4 ( 8.3%), 5 10 (19.6%), 17 Injection Site Nodule 4 ( 8.3%), 5 11 ( 21.6%), 31 InjectionSite Hypersensitivity 2 ( 4.2%), 2 4 ( 7.8%), 9 Injection Site Haematoma2 ( 4.2%), 2 1 ( 2.0%), 1 Injection Site Discolouration 0 ( 0.0%), 0 0 (0.0%), 0 Injection Site Inflammation 0 ( 0.0%), 0 0 ( 0.0%), 0 InjectionSite Reaction 0 ( 0.0%), 0 0 ( 0.0%), 0 Fatigue 0 ( 0.0%), 0 0 ( 0.0%),0 Feeling Hot 0 ( 0.0%), 0 0 ( 0.0%), 0 Hypothermia 0 ( 0.0%), 0 0 (0.0%), 0 Injection Site Urticaria 0 ( 0.0%), 0 0 ( 0.0%), 0 Pyrexia 0 (0.0%), 0 0 ( 0.0%), 0 Investigations: Lymph Node 0 ( 0.0%), 0 0 ( 0.0%),0 Palpable Investigations: Body 0 ( 0.0%), 0 0 ( 0.0%), 0 TemperatureIncreased Blood and Lymphatic System 0 ( 0.0%), 0 1 ( 2.0%), 1Disorders: Lymphadenopathy Gastrointestinal Disorders: 0 ( 0.0%), 0 1 (2.0%), 1 Glossitis Gastrointestinal Disorders: 0 ( 0.0%), 0 0 ( 0.0%), 0Nausea Gastrointestinal Disorders: 0 ( 0.0%), 0 0 ( 0.0%), 0 VomitingNervous System Disorders: 0 ( 0.0%), 0 0 ( 0.0%), 0 Paraesthesia NervousSystem Disorders: 0 ( 0.0%), 0 0 ( 0.0%), 0 Dizziness Cardiac Disorders:Cyanosis 0 ( 0.0%), 0 0 ( 0.0%), 0 Infections and Infestations: 0 (0.0%), 0 0 ( 0.0%), 0 Rash Pustular Musculoskeletal and Connective 0 (0.0%), 0 1 ( 2.0%), 1 Tissue Disorders: Pain in Extremity PsychiatricDisorders: Tension 0 ( 0.0%), 0 0 ( 0.0%), 0 Vascular Disorders:Haematoma 0 ( 0.0%), 0 0 ( 0.0%), 0

2. Immunogenicity of Two Aβ, Targeting Vaccines SeqID 1-KLH-Alum andSeqID 2-KLH Alum in Comparison to KLH-Alum and Alum Only

SeqIDs:

SeqID 1: SWEFRTC

SeqID 2: SEFKHGC

Animal Experiments:

All animal experiments were performed in accordance with the AustrianAnimal Experiments Act (TVG2012) using Tg2576-mice (Taconic Farms, USA;129S6/SvEvTac). General health was checked by modified Smith KlineBeecham, Harwell, Imperial College, Royal London Hospital, phenotypeassessment (SHIRPA) primary observational screen (Rogers D C et al.(1999) Behav Brain Res 105: 207-217.). Mice were injected s.c. 6 timesin monthly intervals. Blood was taken in regular intervals, plasmaprepared and stored until further use. At study end mice weresacrificed, brains were collected and hemispheres separated. Onehemisphere was fixed in 4% Paraformaldehyde (PFA, Sigma Aldrich, USA),dehydrated and paraffin-embedded. Brain tissue was sectioned at 7 μMusing a sliding microtome (Leitz, Germany) and sections were mounted onSuperfrost Plus Slides (Menzel, Germany).

Titer Determination by ELISA:

Standard enzyme-linked immunosorbent assay (ELISA) technology was usedto measure levels of vaccine-induced antibodies in plasma and CSF(Mandler M et al. (2012) J Alzheimers Dis 28: 783-794.). Substrates usedinclude human (BACHEM, CH) Aβ1-40/42 (at 5 μg/ml), KLH (1 μg/ml) andpeptide-Bovine serum albumin (BSA) conjugates (SeqID 1 and SeqID 2, 1μM). Optical density (OD) was measured at 405 nm using a micro-wellreader (Tecan, CH). ODmax/2 was calculated.

Behavioral Tests:

To analyse cognitive dysfunction, immunised Tg2576 animals weresubjected to contextual fear conditioning (CFC, Comery T A et al. (2005)J Neurosci 25: 8898-8902.), analyzed using AnyMaze software (StoeltingCo, USA). For CFC, on day 1 mice were placed in the conditioning chamber(AFFiRiS AG, Austria), allowed to habituate for 2 min. and receivedthree 0.8 mA footshocks in 2 min intervals plus 30 s rest. To assesscontextual learning on day 2, animals were readmitted to the chamber andmonitored for 5 min. with s120-240 chosen as time frame for analysis(time freezing=lack of movement except for respiration). The first twominutes of day 1 were considered as baseline-freezing which wassubtracted from day 2 values.

Analysis of Cerebral Aβ:

Immunofluorescence (IF) analysis was done as described previously(Mandler M et al. (2012) J Alzheimers Dis 28: 783-794). For Aβ-specificIF-staining, brain sections of immunized Tg2576 were processed foranalysis of amyloid load using mAb 3A5 (AFFiRiS AG, Austria). Allsecondary reagents used were obtained from Vector Labs (USA). For IF,sections were mounted and counterstained using DAPI-containingVECTASHIELD-HardSet Mounting Medium. Sections were examined usingMIRAX-SCAN (Carl Zeiss AG, Germany). AD-like pathology in animals wasassessed by determining the relative cerebral area occupied by amyloiddeposits using a semi-automated area recognition program (eDefiniensArchitect XD; www.definiens.com, Mandler M. et al (2015) PLoS ONE 10(1):e0115237.). For analysis three slides/animal and five individualsections/slide were assessed. Sections carrying tissue artifacts oraberrant staining were excluded. To assess the number of Aβ-positivevessels, 3A5 stained sections (3 slides/animal covering cortex andhippocampus and up to five individual sections per slide) have beenanalysed. Aβ-positive vessels were manually counted in subregions of thecortex as well as in the hippocampus. Number of positive vessels per mm²was determined.

References:

-   Rogers et al., Behav Brain Res 105 (1999): 207-217.-   Mandler et al., PLoS ONE 10(1) (2015): e0115237.    doi:10.1371/journal.pone.0115237.-   Mandler et al., J Alzheimers Dis 28: 783-794.-   Comery et al., J Neurosci 25 (2005): 8898-8902.    Results:

To test the immunogenicity of two Aβ targeting vaccines SeqID 1-KLH-Alumand SeqID 2-KLH Alum in comparison to KLH-Alum and Alum(Aluminium-oxyhydroxide) only, Tg2576-mice were injected 6×, s.c., at4-week intervals with either conjugate-vaccine containing 30 μg netpeptide, equivalent doses of KLH formulated with Alum or Alum only. Alumdoses used were equivalent to 2 mg/ml. Vaccination induced Abs weremeasured in plasma samples taken at sacrification (SeqID 1 (n=10), SeqID2 (n=8), KLH-Alum (n=10) and Alum only (n=8)). All 3 vaccines elicitedstrong and comparable IgG titers towards the peptide used forimmunization (FIG. 6A). Alum only did not elicit signals abovebackground (FIG. 6A). Both Aβ targeting vaccines, SeqID 1-KLH-Alum andSeqID 2-KLH-Alum, elicited Abs to human Aβ whereas KLH-Alum vaccine andAlum only did not elicit signals above background in treated animals(FIG. 6B).

To evaluate the effect of Aluminum-oxyhydroxide only (Alum) incomparison to Aβ targeting vaccines (SeqID 1-+SeqID 2-KLH-Alum) and nonAβ specific vaccines (KLH-Alum) on cognitive functions, we appliedContextual Fear Conditioning (CFC) analyzing contextual memory andlearning in Tg2576-mice. As expected, CFC demonstrated that SeqID 1- andSeqID 2-treated mice were superior to control animals receiving KLH-Alum(thus not eliciting an Aβ specific immune response) in this AD model ofAβ deposition (FIG. 7). Interestingly, animals receiving Alum only,(without a conjugate eliciting an active immune response against KLH orAβ, respectively), showed similar effects as detectable with Aβtargeting vaccines in this AD model in the absence of Aβ-specificantibodies.

To test whether Alum would also significantly influence cerebral amyloidload, animals undergoing CFC were subsequently sacrificed at 14 monthsof age. Their brains were assessed for diffuse and dense-cored plaquesby IF-staining using monoclonal antibody 3A5. Cortical as well ashippocampal sections of KLH/ALUM-injected controls were covered bynumerous amyloid plaques (FIG. 8A+C). By contrast, respective brainareas of SeqID 1- and SeqID 2-immunized Tg2576-mice containedsignificantly less deposits (FIGS. 8B+D and E, p<0.05 and data notshown). Importantly, treatment of Tg2576 animals with Alum only did notsignificantly alter amyloid deposition as compared to KLH-Alum treatedanimals (FIG. 8 E) in this AD model.

Thus, FIGS. 7 and 8 also disclose that topically appliedaluminium-oxyhydroxide is able to lower cognitive decline significantlyin an APP-transgenic model for Alzheimer's disease (Tg2576) withoutsignificantly changing cerebral Aβ, levels. This is implying an APP/Aβindependent mechanism underlying beneficial functional effects exertedby aluminium-oxyhydroxide in this AD model and further evidences thelack of scientific plausibility of the “amyloid channel hypothesis”.

It follows that the present invention discloses the followingindividually preferred embodiments:

1. Aluminium oxyhydroxide for use in the treatment and prevention ofAlzheimer's Disease (AD).

2. Aluminium oxyhydroxide for use according to embodiment 1, whereinaluminium oxyhydroxide is contained in a pharmaceutical preparation.

3. Aluminium oxyhydroxide for use according to embodiment 1 or 2,wherein aluminium oxyhydroxide is administered to an AD patient as asuspension.

4. Aluminium oxyhydroxide for use according to any one of embodiments 1to 3, wherein aluminium oxyhydroxide is administered to an AD patient asEuropean Pharmacopoeia grade aluminium-oxyhydroxide (monograph 1664),especially wherein aluminium oxyhydroxide is Alhydrogel.5. Aluminium oxyhydroxide for use according to any one of embodiments 1to 4 in a ready-to-use form to be directly applied to a patient,especially in a prefilled syringe.6. Aluminium oxyhydroxide for use according to any one of embodiments 1to 5 contained in a pharmaceutical preparation, wherein said preparationcontains aluminium oxyhydroxide as the single effective ingredient.7. Aluminium oxyhydroxide for use according to any one of embodiments 1to 6 contained in a pharmaceutical preparation, wherein said preparationfurther comprises auxiliary substances, especially stabilisators,detergents, antioxidants, complexing agents for mono- or divalent metalions, carbohydrates and/or buffer substances.8. Aluminium oxyhydroxide for use according to any one of embodiments 1to 7 contained in a pharmaceutical preparation, wherein said preparationis sterilised and, optionally, liquid, frozen or lyophilised, preferablyliquid.9. Aluminium oxyhydroxide for use according to any one of embodiments 1to 8 contained in a pharmaceutical preparation, wherein said preparationis liquid and has a pH of 5 to 9, preferably of 5.5 to 8.0, especiallyfrom 6 to 7.5.10. Aluminium oxyhydroxide for use according to any one of embodiments 1to 9, wherein aluminium oxyhydroxide is administered in an amount of atleast 0.5 mg (given as Al₂O₃ equivalent) to an AD patient.11. Aluminium salt according to any one of embodiments 1 to 10, whereinaluminium oxyhydroxide is administered in an amount of at least 1.0 mg(given as Al₂O₃ equivalent) to an AD patient.12. Aluminium oxyhydroxide for use according to any one of embodiments 1to 11, wherein aluminium oxyhydroxide is administered in an amount of atleast 1.2 mg (given as Al₂O₃ equivalent) to an AD patient.13. Aluminium oxyhydroxide for use according to any one of embodiments 1to 12, wherein aluminium oxyhydroxide is administered in an amount of1.2 mg to 5.0 mg (given as Al₂O₃ equivalent) to an AD patient.14. Aluminium oxyhydroxide for use according to any one of embodiments 1to 13, wherein aluminium oxyhydroxide is administered in an amount of atleast 1.5 mg (given as Al₂O₃ equivalent) to an AD patient.15. Aluminium oxyhydroxide for use according to any one of embodiments 1to 14, wherein aluminium oxyhydroxide is administered in an amount of1.5 mg to 5.0 mg, preferably 1.5 to 3.0 mg, especially 1.5 to 2.5 mg,(given as Al₂O₃ equivalent) to an AD patient.16. Aluminium oxyhydroxide for use according to any one of embodiments 1to 15, wherein aluminium oxyhydroxide is administered in an amount of1.6 mg to 2.5 mg, preferably 1.8 to 2.2 mg, especially 1.9 to 2.0 mg,(given as Al₂O₃ equivalent) to an AD patient.17. Aluminium oxyhydroxide for use according to any one of embodiments 1to 16 contained in a pharmaceutical preparation, wherein saidpreparation additionally contains one or more stabilisators, especiallythiomersal, detergents, antioxidants, complexing agents for mono- ordivalent metal ions, especially ethylenediaminetetraacetic acid (EDTA),sugars, sugar alcohols, glycerol, and/or buffer substances, especiallyTRIS or phosphate buffer substances.18. Aluminium oxyhydroxide for use according to any one of embodiments 1to 17 contained in a pharmaceutical preparation, wherein saidpreparation is a suspension with a pH of 4 to 10, preferably of 5 to 9,more preferred of 6 to 8, especially from 7.0 to 7.5.19. Aluminium oxyhydroxide for use according to any one of embodiments 1to 18 contained in a pharmaceutical preparation, wherein saidpreparation is an isotonic suspension.20. Aluminium oxyhydroxide for use according to any one of embodiments 1to 19, wherein aluminium oxyhydroxide is administered to an AD patientsubcutaneously, intranodally, intradermally, or intramuscularly,especially subcutaneously.21. Aluminium oxyhydroxide for use according to any one of embodiments 1to 20, wherein aluminium oxyhydroxide is administered to an AD patientat least once monthly for at least two months.22. Aluminium oxyhydroxide for use according to any one of embodiments 1to 21, wherein the aluminium salt is aluminium oxyhydroxide and isadministered at least once monthly for at least six months to an ADpatient.23. Aluminium oxyhydroxide for use according to any one of embodiments 1to 22, wherein aluminium oxyhydroxide is administered at least twice amonth for at least six months, preferably for at least twelve months,especially at least 24 months, to an AD patient.24. Aluminium oxyhydroxide for use according to any one of embodiments 1to 23, wherein aluminium oxyhydroxide is administered to an AD patientsubcutaneously in the upper arm, preferably alternating in the left andin the right upper arm.25. Aluminium oxyhydroxide for use according to any one of embodiments 1to 24, wherein aluminium oxyhydroxide is administered in split doses toan AD patient, especially at the same site of administration.26. Aluminium oxyhydroxide for use according to any one of embodiments 1to 25, wherein aluminium oxyhydroxide is administered in split doses of0.8 to 5.0 mg, preferably of 1.0 to 3.0, especially from 1.0 to 1.5 mg,(given as Al₂O₃ equivalent) to an AD patient.27. Aluminium oxyhydroxide for use according to any one of embodiments 1to 26, wherein aluminium oxyhydroxide is administered at least monthlyfor at least two years, preferably at least four years, especially atleast 8 years, to an AD patient.28. Aluminium oxyhydroxide for use according to any one of embodiments 1to 27, wherein aluminium oxyhydroxide is administered by an injectiondevice, especially a syringe, to an AD patient.29. Aluminium oxyhydroxide for use according to any one of embodiments 1to 28, wherein aluminium oxyhydroxide is administered in an amount of atleast 1.8 mg (given as Al₂O₃ equivalent) to an AD patient.30. Aluminium oxyhydroxide for use according to any one of embodiments 1to 29, wherein aluminium oxyhydroxide is administered to the AD patientin liquid form in an application volume of 0.1 to 10 ml, preferably of0.2 to 5 ml, especially of 0.4 to 3 ml.31. Aluminium oxyhydroxide for use according to any one of embodiments 1to 30 contained in a pharmaceutical preparation, wherein saidpreparation is devoid of sulphate, nitrate, or chloride anions.32. Aluminium oxyhydroxide for use according to any one of embodiments 1to 31 contained in a pharmaceutical preparation, wherein saidpreparation has a heavy metal content of less than 20 ppm.33. Aluminium oxyhydroxide for use according to any one of embodiments 1to 32 contained in a pharmaceutical preparation, wherein saidpreparation is a suspension of aluminium oxyhydroxide and has a particlesize distribution between 2 μm and approximately 10 μm, said particlesbeing aggregates, composed of smaller fibers of preferably about 2nm×4.5 nm×10 nm.34. Aluminium oxyhydroxide for use according to any one of embodiments 1to 33, wherein aluminium oxyhydroxide is administered in an amount of atleast 2.2 mg, preferably 2.2 to 10 mg, more preferred of 2.2 to 8 mg,even more preferred of 2.2 to 5 mg, especially 2.2 to 4 mg, (given asAl₂O₃ equivalent) to an AD patient.35. Aluminium oxyhydroxide for use according to any one of embodiments 1to 34, wherein aluminium oxyhydroxide is administered to an AD patientwith an MMSE score of between 23 and 30, preferably between 24 and 30,more preferably between 25 and 29, especially between 26 and 29.36. Aluminium oxyhydroxide for use according to any one of embodiments 1to 35, wherein aluminium oxyhydroxide is administered to an AD patientwith an MMSE score of greater than or equal to 27.37. Aluminium oxyhydroxide for use according to any one of embodiments 1to 35, wherein aluminium oxyhydroxide is administered to an AD patientwith an MMSE score of 25 to 27.38. Aluminium oxyhydroxide for use according to any one of embodiments 1to 35, wherein aluminium oxyhydroxide is administered to an AD patientwith an MMSE score of 19 to 24.

The invention claimed is:
 1. A method for treating Alzheimer's Disease(AD), the method comprising administering a pharmaceutical preparationto an AD patient, said pharmaceutical preparation comprising a EuropeanPharmacopoeia grade aluminum oxyhydroxide in an amount of at least 1.2mg as a single effective ingredient to treat AD.
 2. The method of claim1, comprising directly applying the aluminum oxyhydroxide in aready-to-use form to the AD patient.
 3. The method of claim 1, whereinthe aluminum oxyhydroxide is administered in an amount of 1.5 mg to 5.0mg to the AD patient.
 4. The method of claim 1, wherein saidpharmaceutical preparation further comprises at least one selected fromthe group consisting of a stabilizer, a detergent, a non-therapeuticamount of an antioxidant, a complex agent for mono- or divalent metalions, a sugar, a sugar alcohol, a glycerol and a buffer.
 5. The methodof claim 1, wherein the aluminum oxyhydroxide is administered to the ADpatient subcutaneously, intranodally, intradermally, or intramuscularly.6. The method of claim 1, wherein the aluminum oxyhydroxide isadministered at least once monthly for at least six months to the ADpatient.
 7. The method of claim 1, wherein the aluminum oxyhydroxide isadministered to the AD patient subcutaneously in the upper arm.
 8. Themethod of claim 1, wherein the aluminum oxyhydroxide is administered toan AD patient with a Mini-Mental State Examination (MMSE) score ofbetween 23 and
 30. 9. The method of claim 1, wherein the aluminumoxyhydroxide is administered to an AD patient with an MMSE score ofgreater than or equal to
 27. 10. The method of claim 1, wherein thealuminum oxyhydroxide is administered to an AD patient with an MMSEscore of 25 to
 27. 11. The method of claim 1, wherein the aluminumoxyhydroxide is administered in an amount of at least 2.2 mg to the ADpatient.
 12. The method of claim 1, wherein the aluminum oxyhydroxide isadministered to the AD patient in liquid form in an application volumeof 0.1 to 10 ml.